System, Method and Computer Program Product for Administering Consumer Care Initiatives

Abstract

Consumer care initiatives are implemented by comparing recommended healthcare services with services assumed to have been received by the consumer which are identified through analyzing real-time consumer data. Based on the comparison, assumed gap closures in care are identified, and a consumer outreach suppression period is initiated for the one or more recommended healthcare services with the assumed gap closure during which an outreach initiative is inactive. Reactivation of the initiative may occur when the assumed gap closure is unconfirmed, or the initiative is removed when the healthcare services associated with the assumed gap closure is confirmed to have been received by the consumer. Evaluation of the real-time consumer data further allows for identification of a new disease or condition the consumer is assumed to be experiencing, resulting in the identification of assumed quality gap openings, which enables new care initiatives to be added to the consumer's outreach plan.

What is claimed is: 
     
         1 . A computer-implemented method for improving consumer care initiatives, the method comprising:
 (a) retrieving consumer data comprising at least consumer healthcare plan eligibility, historic claims data, recently adjudicated medical claim data, recently adjudicated medication prescription claim data and recent laboratory procedure data using a computer processor;   (b) analyzing the consumer data against a set of predefined business rules to identify a group of healthcare services recommended for the consumer using the computer processor;   (c) analyzing the consumer data to identify services performed and comparing to the group of recommended healthcare services to identify a match therebetween using the computer processor, said match based on one or more of a diagnosis code, a procedure code, a medication identifier or a lab procedure identified in the consumer data;   (d) identifying a group of remaining recommended healthcare services recommended for the consumer using the computer processor;   (e) retrieving real-time consumer data comprising one or more of a diagnosis code, a procedure code, a medication identifier or a lab procedure, wherein the real-time consumer data has not been adjudicated;   (f) analyzing the real-time consumer data against a set of predefined business rules to identify services performed based on the one or more of a diagnosis code, a procedure code, a medication identifier or a lab procedure in the real-time consumer data;   (g) comparing the identified services to the group of remaining recommended healthcare services to identify an assumed match therebetween using the computer processor, said assumed match corresponding to an assumption that the consumer received one or more remaining recommended healthcare services from the group;   (h) initiating a consumer outreach suppression period for the one or more remaining recommended healthcare services with the assumed match during which the one or more remaining recommended healthcare services are assumed to be received and an initiative to engage the consumer in receiving services associated with the assumed match is inactive in a consumer initiative queue using the computer processor; and   (i) re-activating the outreach initiative after a period of time when the assumed match between the recommended and received healthcare services is unconfirmed from adjudicated claim data, or removing the initiative after the period of time when the assumed match is confirmed from adjudicated claim data using the computer processor.   
     
     
         2 . The method of  claim 1 , wherein the predefined business rules are derived from evidence-based medicine guidelines. 
     
     
         3 . The method of  claim 2 , wherein the predefined business rules are further derived from healthcare performance measures. 
     
     
         4 . The method of  claim 2 , wherein the healthcare performance measures are Healthcare Effectiveness Data and Information Set (“HEDIS”) measures. 
     
     
         5 . The method of  claim 1 , wherein the historic claims data is about two to ten years of past claims data for the consumer. 
     
     
         6 . The method of  claim 1 , wherein the recent medical claims data comprises monthly aggregations of claims data. 
     
     
         7 . The method of  claim 1 , wherein the real-time consumer data comprises one or more of pre-adjudicated medical claims data, prescription claims data or laboratory procedure data. 
     
     
         8 . The method of  claim 1 , wherein the step of retrieving the real-time consumer data further comprises retrieving consumer data comprising at least consumer healthcare plan eligibility, two to ten years of historic claims data and electronic medical records. 
     
     
         9 . The method of  claim 1 , wherein the real-time consumer data is derived from claims that have not been paid. 
     
     
         10 . The method of  claim 9 , wherein data from the claims that have not been paid is parsed from an Accredited Standards Committee X12 837 claim feed format. 
     
     
         11 . The method of  claim 1 , further comprising:
 analyzing the real-time consumer data against the set of predefined business rules to identify a group of healthcare services recommended for the consumer using the computer processor; and   activating a further initiative in the consumer initiative queue to engage the consumer in receiving the group of healthcare services recommended for the consumer.   
     
     
         12 . The method of  claim 11 , further comprising initiating an engagement suppression period during which the further initiative is inactive in the consumer initiative queue. 
     
     
         13 . A computer system, the system comprising:
 a computer processor configured to:
 (a) access a consumer activation plan stored in memory, the consumer activation plan comprising a group of recommended healthcare services recommended for a consumer based on comparing a health history and previously adjudicated claims of the consumer with evidence-based medicine guidelines; 
 (b) retrieve real-time consumer data comprising one or more of a diagnosis code, a procedure code, a medication identifier or a lab procedure, wherein the real-time consumer data has not been adjudicated; 
 (c) analyze the real-time consumer data against a set of predefined business rules to identify services performed based on the one or more of a diagnosis code, a procedure code, a medication identifier or a lab procedure identified in the real-time consumer data; 
 (d) compare the identified services to the group of recommended healthcare services to identify an assumed match therebetween, said assumed match corresponding to an assumption that the consumer received one or more recommended healthcare services from the group; 
 (e) initiate a consumer outreach suppression period for the one or more recommended healthcare services with the assumed match during which the one or more recommended healthcare services are assumed to be received and an initiative to engage the consumer in receiving services associated with the assumed match is inactive; and 
 (f) re-activate the outreach initiative after a period of time when the assumed match between the recommended and received healthcare services is unconfirmed from adjudicated claim data, or remove the initiative after the period of time when the assumed match is confirmed from adjudicated claim data. 
   
     
     
         14 . The system of  claim 13 , wherein the computer processor is further configured to:
 analyze the real-time consumer data against evidence-based medicine guidelines to identify a group of healthcare services recommended for the consumer using the computer processor; and   activate a further outreach initiative to engage the consumer in receiving the group of healthcare services recommended for the consumer.   
     
     
         15 . The method of  claim 14 , wherein the computer processor is further configured to:
 initiate an engagement suppression period during which the further outreach initiative is inactive based on an assumed match.   
     
     
         16 . The method of  claim 15 , wherein the computer processor is further configured to:
 re-activate the further outreach initiative after the engagement suppression period in which the assumed match between the recommended and received healthcare services is unconfirmed based on adjudicated claim data, or removing the further outreach initiative after the engagement suppression period based on confirming the one or more healthcare services associated with the assumed match were received based on the adjudicated claim data thereby confirming the assumed match is an actual match.   
     
     
         17 . The method of  claim 13 , wherein analyzing further comprises determining at least one diagnosis code or procedure code in the real-time consumer data and analyzing the at least one code against the evidence-based medicine guidelines to identify the group of healthcare services recommended for the consumer. 
     
     
         18 . One or more non-transitory computer readable storage media encoded with instructions executable by a processor of a computing system, the instructions comprising instructions for:
 (a) accessing a group of recommended healthcare services for a consumer;   (b) analyzing the real-time consumer data to identify services performed based on one or more of a diagnosis code, a procedure code, a medication identifier or a lab procedure associated with the real-time consumer data;   (c) comparing the identified services to the group of recommended healthcare services to identify an assumed match therebetween, said assumed match corresponding to an assumption that the consumer received one or more recommended healthcare services from the group;   (d) initiating a consumer outreach suppression period for the one or more recommended healthcare services with the assumed match during which the one or more recommended healthcare services are assumed to be received and an initiative to engage the consumer in receiving services associated with the assumed match is inactive; and   (e) re-activating the outreach initiative when the assumed match between the recommended and received healthcare services is unconfirmed from adjudicated claim data, or removing the initiative when the assumed match is confirmed from adjudicated claim data.   
     
     
         19 . The non-transitory computer readable storage media of  claim 18 , wherein the real-time consumer data comprises one or more of pre-adjudicated medical claims data, prescription claims data or laboratory procedure data. 
     
     
         20 . The non-transitory computer readable storage media of  claim 18 , wherein the real-time consumer data is parsed from claims feeds.